Coila Edgar-Retinitis pigmentosa-(Peru)-Posted on Mar.24th,2015

Author Zhangqi Views Posted at 2015/03/24

Name: Coila Aguilar Jose Edgar
Sex: Male
Country: Peru
Age: 44 years
Diagnosis: 1.Retinitis pigmentosa 2. Hyperlipemia
Date: Feb. 17th, 2015
Days Admitted to Hospital: 23 days

Before treatment:
In the year 2000, the patient experienced decrease in vision with no apparent reason at dusk. In 2002, his sight in the evening was worse. His disease gradually became worse. In 2010, his sight became worse suddenly. He couldn’t drive during daytime. He went to hospitals in Mexico and Argentina. It was considered as gene disease and diagnosed with “Retinitis pigmentosa”. But he didn’t receive any treatment. His sight became worse, he could only see the outline of people at the distance of 3 meters. He could see the arm but not the fingers at the distance of 2 meters. His sight was worse at night. His color sensitivity was normal. He wants to have a better treatment, so he came to our hospital and he was diagnosed with “retinitis pigmentosa”.

He was in good spirit. His sleep, eating, urination and excrement were good.

Admission PE:
Bp: 135/80mmHg; Hr: 84/min, Br: 19/min. He’s growth and nutrition were normal. His skin mucosa was without hemorrhaging spots or yellow stains. His thorax was symmetrical. The respiration of both lungs was clear, without moist rales. The heart sound was strong, and the cardiac rhythm was regular, and there was no obvious murmur in the valves. The abdomen was flat and soft, with no masses. The liver and spleen were normal.

Nervous System Examination:
He was alert and his speech was clear. His memory, orientation and calculation ability were normal. The diameter of both pupils was 3.0mms and both pupils were sensitive to direct and indirect light reflex. His peripheral visual field was normal. Visual acuity test (3-meter visual acuity test chart): both eye’s corrected visual acuity were 0.1. Left eye naked vision was 0.06 and right eye was 0.12 at the distance of 1 meter. Right eye naked vision was 0.06 at the distance of 2 meters. It was hard for him to distinguish the congenial colors. Through use of an ophthalmoscope: the color of right retina was light red. There were black osteoid lees. The optic papilla was clear, the boundary was not clear. The macula flava retinae was clear. AV ratio of both eyes were 1:3. The color of left retina was light red. There were a lot of black osteoid lees. The optic papilla was not hydropic, the boundary was clear. The macula flava retinae was clear. AV ratio of both eyes were 1:3. The movement of eyeballs to each side was good and there was no obvious nystagmus. The forehead wrinkle pattern was symmetrical. The nasolabial sulcus was equal in depth. The teeth were symmetrical and the tongue was centered. There was free movement in the neck. The muscle tone of all four limbs was normal. The muscle strength of all four limbs was at level 5. The abdominal reflex was normal. The tendon reflexes in four limbs were normal. The sucking reflex and palm jaw reflex was negative. The bilateral Hoffmann’s sign, Rossolimo’s sign and both side Babinski’s sign were negative. The deep and shallow sensation was normal. The coordinated movements were normal. The meningeal irritation sign was negative.

Treatment:
We gave him a complete examination and he was diagnosed with retinitis pigmentosa and hyperlipemia. He received treatment for nerve regeneration and to activate stem cells in the body. He received treatment to improve the blood circulation in order to increase the blood supply to the damaged neurons and to nourish them and he received treatment to decrease blood-lipid.

Post-treatment:
After the treatment, Visual acuity test (3-meter visual acuity test chart): both eye’s corrected visual acuity were 0.25. Left eye naked vision was 0.08 at the distance of 1.5 meters. Right eye naked vision was 0.12 at the distance of 3 meters. The black osteoid lees on the ambitus was less. The color of retina was redder, others were the same to before. At present, Coila Aguilar Jose Edgar’s treatment has been completed and the discharge has been permitted.